Anthony Hamm

DC

HEALTHCARE QUALITY AND MEASUREMENT

ANTHONY W. HAMM, DC, MS

NOVEMBER 2019

DISCLOSURES

• PAST PRESIDENT ACA

• CHIEF CLINICAL OFFICER SPINE IQ

• PRESIDENT WEST HARTFORD GROUP

• CYNIC

OUTLINE

• HISTORY AND BACKGROUND

• DEFINITIONAL ATTRIBUTES OF HEALTHCARE QUALITY

• MEASURE TYPES AND DOMAINS

• STAKEHOLDERS

• MEASURE DEVELOPMENT

• UTILIZATION

• PRACTICE IMPROVEMENT

HISTORY AND BACKGROUND

• PRACTICE AND PAYMENT POLICIES:

• PRE 1970`S

• 1970`S THROUGH PRESENT

• 2007 PQRI, THEN PQRS, FOLLOWED BY MIPS

FEDERAL CODES AND REGULATIONS

• HEALTH AND HUMAN SERVICES

• FEDERAL TRADE COMMISSION

• DEPARTMENT OF THE INTERIOR

• DEPARTMENT OF LABOR

• DEPARTMENT OF DEFENSE/VETERAN HEALTH ADMINISTRATION

BARRIERS AND OBSTACLES TO CHANGE

• AMA AND CMS BIAS

• PUBLIC TRUST

• FUNDING/POLITICAL ACTION

• INTRAPROFESSIONAL DISCORD

• STATE SCOPE VARIANCE

• BUDGET NEUTRALITY

POSITIONS SUPPORTED BY ACA

• AMA CPT AND RUC

• PCPI

• MEDICARE CARRIER ADVISORY COMMITTEES

• VARIOUS GUIDELINE REVIEW COMMENTARIES

• US BONE AND JOINT INITIATIVE

• PCORI

• NIH

• NCQA

CROSSING THE QUALITY CHASM (NASEM)

• US HEALTHCARE SYSTEM DOES NOT PROVIDE CONSISTENT HIGH-QUALITY CARE TO ALL PEOPLE

• [PEOPLE] SHOULD BE ABLE TO COUNT ON RECEIVING CARE THAT MEETS INDIVIDUAL NEEDS AND IS GROUNDED

ON THE BEST SCIENTIFIC KNOWLEDGE

• FREQUENTLY NOT THE CASE…….

INSTITUTE OF MEDICINE(2001) CROSSING THE QUALITY CHASM: A NEW HEALTH SYSTEM FOR THE 21ST

CENTURY. NATIONAL ACADEMIES PRESS

THE NATIONAL QUALITY STRATEGY

• THREE AIMS

• SIX PRIORITIES

THREE AIMS

• BETTER CARE: IMPROVE THE OVERALL QUALITY OF CARE BY MAKING HEALTH CARE MORE

PATIENT- CENTERED, RELIABLE, ACCESSIBLE, AND SAFE.

• HEALTHY PEOPLE/HEALTHY COMMUNITIES: IMPROVE THE HEALTH OF THE U.S. POPULATION

BY SUPPORTING PROVEN INTERVENTIONS TO ADDRESS BEHAVIORAL, SOCIAL, AND

ENVIRONMENTAL DETERMINANTS OF HEALTH IN ADDITION TO DELIVERING HIGHER QUALITY

CARE.

• AFFORDABLE CARE: REDUCE THE COST OF QUALITY HEALTH CARE FOR INDIVIDUALS,

FAMILIES, EMPLOYERS, AND GOVERNMENT.

TRIPLE AIM

• PATIENT EXPERIENCE

• IMPROVING POPULATION HEALTH

• REDUCING COSTS

SIX PRIORITIES

• MAKING CARE SAFER BY REDUCING HARM CAUSED IN THE DELIVERY OF CARE

• ENSURING THAT EACH PERSON AND FAMILY IS ENGAGED AS A PARTNER IN THEIR CARE

• PROMOTING EFFECTIVE COMMUNICATION AND COORDINATION OF CARE

• PROMOTING THE MOST EFFECTIVE PREVENTION AND TREATMENT PRACTICES

• WORKING WITH COMMUNITIES TO PROMOTE WIDE USE OF BEST PRACTICES TO ENABLE

HEALTHY LIVING

• MAKING QUALITY CARE MORE AFFORDABLE FOR INDIVIDUALS, FAMILIES, EMPLOYERS, AND

GOVERNMENTS BY DEVELOPING AND SPREADING NEW HEALTH CARE DELIVERY MODELS

DEFINITIONAL ATTRIBUTES OF HEALTHCARE QUALITY

• TECHNICAL PERFORMANCE

• PATIENT-CENTEREDNESS

• AMENITIES

• ACCESS

• EQUITY

• EFFICIENCY

• COST-EFFECTIVENESS

STAKEHOLDER PERSPECTIVES ON QUALITY

• CLINICIANS

• PATIENTS

• PAYERS

• MANAGERS

• SOCIETY

WHY QUALITY MATTERS

• MOVEMENT TOWARDS VALUE-BASED PAYMENT MODELS

• FEE-FOR-SERVICE MODEL DIMINISHING

• OUTCOMES DRIVEN PAYMENT SYSTEMS

• CMS PHYSICIANS COMPARE INITIATIVE…CONSUMER DRIVEN

WHY QUALITY MATTERS

• THE ENTIRETY OF QUALITY DRIVEN HEALTHCARE IS BASED ON THE PREMISE THAT OUR

COLLECTIVE SYSTEMS CAN DO A BETTER JOB (CHIROPRACTIC?)

• AND IF WE CANNOT MEASURE SOMETHING, WE CANNOT IMPROVE IT!

• HENCE THE PUSH TOWARDS CLINICAL QUALITY REPORTING

CLINICAL QUALITY REPORTING

• TRACK OUTCOMES

• IMPROVE PATIENT FOLLOW-UP

• DEMONSTRATE VALUE

• CONTRIBUTE REAL DATA TOWARDS RESEARCH

• CURRENT REGISTRIES SUPPORTING CHIROPRACTIC?

CLINICAL QUALITY MEASURES

USED TO ASSESS THE PERFORMANCE OF INDIVIDUAL CLINICIANS, DELIVERY ORGANIZATIONS, OR

HEALTH PLANS, WHICH ARE SUPPORTED BY EVIDENCE DEMONSTRATING THAT THEY INDICATE

BETTER OR WORSE CARE

CLINICAL MEASURES DOMAINS

• COMMUNICATION AND CARE COORDINATION

• COMMUNITY/POPULATION HEALTH

• EFFECTIVE CLINICAL CARE

• EFFICIENCY AND COST REDUCTION

• PATIENT SAFETY

• PERSON-CENTERED EXPERIENCE AND OUTCOMES

PROCESS MEASURES

• PROCESS MEASURES ARE SUPPORTED BY EVIDENCE THAT THE CLINICAL PROCESS—THAT IS THE FOCUS OF THE

MEASURE—HAS LED TO IMPROVED OUTCOMES.

• THESE MEASURES ARE GENERALLY CALCULATED USING PATIENTS ELIGIBLE FOR A SERVICE IN THE

DENOMINATOR, AND THE PATIENTS WHO EITHER DO OR DO NOT RECEIVE THE SERVICE IN THE NUMERATOR

• EXAMPLE: USE OF IMAGING STUDIES FOR LOW BACK PAIN

• PERCENTAGE OF PATIENTS 18-50 YEARS OF AGE WITH A DIAGNOSIS OF LOW BACK PAIN WHO DID NOT

HAVE AN IMAGING STUDY (PLAIN X-RAY, MRI, CT SCAN) WITHIN 28 DAYS OF THE DIAGNOSIS.

• DOMAIN: EFFICIENCY AND COST REDUCTION

OUTCOME MEASURES• OUTCOME MEASURES ARE SUPPORTED BY EVIDENCE THAT THE MEASURE HAS BEEN USED TO DETECT THE

IMPACT OF ONE OR MORE CLINICAL INTERVENTIONS.

• MEASURES IN THIS DOMAIN ARE ATTRIBUTABLE TO ANTECEDENT HEALTH CARE AND SHOULD INCLUDE

PROVISIONS FOR RISK-ADJUSTMENT.

• EXAMPLE: CHANGE IN PAIN INTENSITY

• AVERAGE PERCENT CHANGE IN PAIN INTENSITY BETWEEN THE FIRST DATE OF A CARE ENCOUNTER AND

EACH SUBSEQUENT ENCOUNTER CLOSEST TO A 14- DAY INTERVAL DURING THE REPORTING PERIOD FOR

PATIENTS AGED 18 YEARS AND OLDER WITH A DIAGNOSIS OF NECK OR LOW BACK PAIN.

• DOMAIN: EFFECTIVE CLINICAL CARE

MAJOR PHYSICIAN MEASUREMENT SETS

• HEDIS

• CORE QUALITY MEASURES COLLABORATIVE

• CAHPS

• PHYSICIANS CONSORTIUM FOR PERFORMANCE IMPROVEMENT (PCPI)

• PROMIS

• NATIONAL QUALITY MEASURES CLEARINGHOUSE

CLINICAL QUALITY MEASURES

• STEWARDS

• SPECIALTY SOCIETIES

• MAINTENANCE

• TEP

• APPROVAL THROUGH NQF AND/OR CMS

• QCDR SELF-NOMINATION PROCESS

FULCRUM HEALTH SUPPORTED OUTCOME MEASURES

• OSWESTRY LOW BACK (SELF-RATED % LOW BACK DISABILITY)

• NECK PAIN DISABILITY INDEX (SELF-RATED % NECK PAIN DISABILITY)

• DASH (SELF-RATED UPPER EXTREMITY FUNCTION SCALE, 30 QUESTIONS))

• LEFS (SELF-RATED LOWER EXTREMITY FUNCTIONAL SCALE, 20 QUESTIONS)

• HEADACHE DISABILITY INDEX (SELF-REPORTED HEADACHE DISABILITY)

• START BACK (INITIAL OUTCOME RISK ASSESSMENT FOR PROGNOSTIC PURPOSES)

• PROMIS 10 (SYMPTOMS, FUNCTION AND HCQOL FOR VARIETY OF CHRONIC DISEASES)

REMEMBER THE SIX NQS PRIORITIES?

• REDUCE HARM

• EFFECTIVE COMMUNICATION

• EFFECTIVE TREATMENT PRACTICES (BEST PRACTICES)

SHOULD WE UTILIZE PROCESS MEASURES?

• IMPROVE YOUR PRACTICE

• ENHANCE PATIENT EXPERIENCE

• ADVANCE YOUR CLINICAL SKILLS

• MANAGE RISK

• BECOME PATIENT-CENTERED

• AVOID LOW-VALUE PRACTICES

• DEVELOP YOUR OWN MEASURES AND INCLUDE STAFF

MEASURES TO IMPLEMENT IN YOUR PRACTICE

• 2018 MIPS MEASURE #128: PREVENTIVE CARE AND SCREENING: BODY MASS INDEX (BMI)

SCREENING AND FOLLOW-UP PLAN

• RECORD HEIGHT AND WEIGHT, CALCULATE BMI

• IF OUTSIDE NORMAL PARAMETERS, CREATE A TREATMENT PLAN

MEASURES TO IMPLEMENT

• NQF #148 PREVENTIVE CARE AND SCREENING: SCREENING FOR DEPRESSION AND FOLLOW-

UP PLAN

• NQS DOMAIN: COMMUNITY AND POPULATION HEALTH

• PERCENTAGE OF PATIENTS 12 YEARS AND OLDER SCREENED FOR DEPRESSION WITH A

STANDARDIZED TOOL, AND IF POSITIVE A FOLLOW-UP PLAN

• CW 4: DO NOT PROVIDE LONG TERM PAIN MANAGEMENT WITHOUT PSYCHOSOCIAL

SCREENING OR ASSESSMENT

MEASURES TO IMPLEMENT

• QUALITY ID# 317 PREVENTIVE CARE AND SCREENING: SCREENING FOR HIGH BLOOD

PRESSURE AND FOLLOW-UP DOCUMENTED

• COMMUNITY AND POPULATION HEALTH

CHECKLISTS FOR QUALITY (ATUL GAWANDE)

• MINIMIZE RISK

• REDUCE HARM

• IMPROVE COMMUNICATION

• IMPROVE CLINICAL SKILLS

ATUL GAWANDE (2009) THE CHECKLIST MANIFESTO, HOW TO GET THINGS DONE RIGHT, METROPOLITAN BOOKS

CHECKLISTS FOR QUALITY

• REVIEW INTAKE FORMS

• HISTORY

• PHYSICAL EXAMINATION

• SPECIAL TESTS

• DIAGNOSTIC ACCURACY

• CONSENT

• TREATMENT PLANS

EXAMPLE

• INCOMPLETE INTAKE FORMS: PERCENTAGE OF INCOMPLETE PATIENT GENERATED INTAKE

FORMS FOR NEW OR RENEWAL PATIENTS

• INVERSE MEASURE (HIGHER THE SCORE, MORE PROBLEMATIC)

• REPORTING PERIOD 90 DAYS

• NUMBER OF INCOMPLETE FORMS AFTER STAFF REVIEW/TOTAL NUMBER OF NEW OR RENEWAL

PATIENTS

• EFFECTIVE CLINICAL CARE AND SAFETY

EXAMPLE

• COMPLETE AND DOCUMENTED CLINICALLY APPROPRIATE EXAMINATION FINDINGS FOR A

PATIENT WITH RADICULAR COMPLAINTS: PERCENTAGE OF PATIENTS IN A REPORTING PERIOD

3-6 MONTHS) WITH COMPLETE AND DOCUMENTED PHYSICAL FINDINGS

• BASED ON RECORDS REVIEW

• SELF-ADMINISTERED AUDIT

• PATIENT SAFETY AND EFFECTIVE CLINICAL CARE

• DEVELOP YOUR OWN CHECKLIST

REMEMBER, IF YOU DON’T MEASURE IT, YOU CANNOT

IMPROVE IT

QUESTIONS